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Systemic treatment of children and adolescents with atopic dermatitis aged ≥2 years: a Delphi consensus project
M de Graaf1, S R Janmohamed2, M L A Schuttelaar3
1Department of Dermatology and Allergology, National Expertise Center for Atopic Dermatitis, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.
Insights
Systemic therapies like cyclosporine A, dupilumab, and methotrexate are recommended for moderate-to-severe paediatric atopic dermatitis (AD) in children aged 2 years and older. Expert consensus provides practical guidance for managing this condition when non-systemic treatments fail.
Area of Science:
- Dermatology
- Paediatric Medicine
- Clinical Pharmacology
Background:
- Paediatric atopic dermatitis (AD) significantly impacts children's quality of life and mental health.
- Existing guidelines lack practical recommendations for systemic therapy in childhood AD, especially for newer agents like biologics and Janus kinase (JAK) inhibitors.
Purpose of the Study:
- To develop practical recommendations for using systemic therapies in children and adolescents (≥2 years) with moderate-to-severe AD.
- To aid clinical decision-making regarding established and novel systemic treatments for paediatric atopic dermatitis.
Main Methods:
- A two-round Delphi process involving 19 Northern European paediatric dermatology experts.
- Consensus was sought on 37 statements regarding the management of moderate-to-severe paediatric AD with systemic therapies.
Main Results:
- Systemic therapy is indicated for severe, persistent paediatric AD unresponsive to optimized non-systemic treatments.
- Cyclosporine A is recommended for short-term use (all ages), while dupilumab and methotrexate are suggested for long-term use in children ≥6 years.
- Consensus was not reached on optimal long-term systemics for children aged 2-6 years, with anticipation of new biologics and JAK inhibitors for this age group.
Conclusions:
- Practical recommendations supplement existing guidelines for systemic treatment of moderate-to-severe paediatric AD.
- The consensus considered available systemic medications including azathioprine, cyclosporine A, dupilumab, methotrexate, mycophenolate mofetil, and oral glucocorticosteroids.
- Recommendations are tailored for Northern European contexts, acknowledging healthcare system and reimbursement variations.
Background:
Paediatric atopic dermatitis (AD) can be burdensome, affecting mental health and impairing quality of life for children and caregivers. Comprehensive guidelines exist for managing paediatric AD, but practical guidance on using systemic therapy is limited, particularly for new therapies including biologics and Janus kinase (JAK) inhibitors, recently approved for various ages in this indication.
Objectives:
This expert consensus aimed to provide practical recommendations within this advancing field to enhance clinical decision-making on the use of these and other systemics for children and adolescents aged ≥2 years with moderate-to-severe AD.
Methods:
Nineteen physicians from Northern Europe were selected for their expertise in managing childhood AD. Using a two-round Delphi process, they reached full or partial consensus on 37 statements.
Results:
Systemic therapy is recommended for children aged ≥2 years with a clear clinical diagnosis of severe AD and persistent disease uncontrolled after optimizing non-systemic therapy. Systemic therapy should achieve long-term disease control and reduce short-term interventions. Recommended are cyclosporine A for short-term use (all ages) and dupilumab or methotrexate for long-term use (ages ≥6 years). Consensus was not reached on the best long-term systemics for children aged 2-6 years, although new systemic therapies will likely become favourable: New biologics and JAK inhibitors will soon be approved for this age group, and more trial and real-world data will become available.
Conclusions:
This article makes practical recommendations on the use of systemic AD treatments for children and adolescents, to supplement international and regional guidelines. It considers the systemic medication that was available for children and adolescents with moderate-to-severe AD at the time this consensus project was done: azathioprine, cyclosporine A, dupilumab, methotrexate, mycophenolate mofetil and oral glucocorticosteroids. We focus on the geographically similar Northern European countries, whose healthcare systems, local preferences for AD management and reimbursement structures nonetheless differ significantly.
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